Post on 27-Sep-2015
description
KORAN BEDAH SARAF 20 MARET 2015
KORAN BEDAH SARAF 28 MARET 2015
LONTARA 3 BEDAH SARAF KAMAR 1
1K1B1
Dioni monjai
548947
21-11-1965
MRS :
26/2/2015Dr,dr djoko widodo Sp BSS : keluhan tidak adaO: Keadaan umum baik Tensi 150/90 mmHgGCS 15 (E4M6V5)
Pupil isokorA: intracranial tumorHipertensi heart diseaseTerapi sesuai TS kardiologiMonitor tensi /12jam
Rencana operasi menunggu jadwalLab 20/3/2015
Na: 144
K : 3,3
Cl : 100
Lab18/2/2015
PT/APTT 10,3/25,2
Ur/Cr 24/0,96
SGOT/SGPT 30/43
WBC 9,44
RBC 5,62
HGB 16,6
2K1B2
Muh. Alvin
689408
3-10-2014
MRS :
16/2/2015
Dr. dr. Nasrullah, Sp.BS S: Luka pada regio parietal semakin kering
Kepala membesar
O: kesan sakit sedang GCS 15(e4m6v5)
Region parietal bilateral
Luka parietal kiri: kering. Luka parietal kanan agak basahA: Hidrocephalus + ulkus decubitus region parietal bilateral-Cefixime syr cth/12j/oral
-Metronidazole syr 3/4cth/8j/oral
-Paracetamol syr 3/4cth /8j/iv
-Rawat luka dengan oxoferin /12 jamTerapi sesuai TS Pediatri
Lab 22-3-2015
Na: 140
K: 6.0
Cl: 110Lab 18/3/2015
WBC 12,1RBC 4.04HGB 11,0HCT 37PLT 489
GDS 88
Ur/Cr 16/0,21
SGOT 38
SGPT 32
Lab 15/3/2015
Na/K/Cl : 142/6,2/109
LONTARA 3 BEDAH SARAF KAMAR 2
1K2B1
Aminsan
705070
18-5-2000MRS :17/3/2015Dr Andi Ihwan, Sp. BS S : gelisah berkurangO : KU baik.
GCS 15 (E4M6V5)
Pupil isokorA :TCS GCS 13 perbaikan GCS 15Maxillofacial injuryCefadroxil 500mg/12 jam/oralAsam mefenamat 500mg/8jam/oral
Ranitidine 150mg/8jam/oral
Neurodex 1 tablet/12jam/oral
Diet sesuai TS gizi klinik,ortopedi,bedah plastikLab 21/3/2015RBC 3.99
HGB 10.7
HCT 31.4
PLT 341
WBC 12,4
Protein total:7.4
Albumin 4.1
Lab 19/3/2015RBC 2,88
HGB 7,8
HCT 22,6
PLT 275
WBC 10,9
Na/Ka/Kl 141/4,4/110
Lab 17/3/2015
WBC 11,6
RBC 4,73HGB 12,8HCT 34,6
2.K2B2
Gaslar
702404
20-9-1974
MRS:
20/3/2015Dr,dr djoko widodo Sp BSS: visus menurunO:keadaan umum baik GCS 15 (E4M6V5)Pupil isokor
A:Intracranial tumorTunggu jadwal operasi
Rencana removal tumorLab 2/3/2015
RBC:4,54
HGB:14,7
HCT:42
PLT:218
WBC:6,3
GDS:148
Ur/Cr:16/0,90
SGOT/SGP:48/59Na/Ka/Kl 145/3,4/109
LONTARA 3 BEDAH SARAF KAMAR 5
1K5B1
Salama
705565
2-10-1943
MRS
20-3-2014Dr. Andi Ihwan Sp BSS: nyeri kepala berkurangO: kesan sakit sedang GCS 14 (E3M6V5)
Pupil isokor 3mm/3mm
Luka telinga kiri kering
A: trauma capitis sedang GCS 11 perbaikan GCS 14
Subarachnoid hematom Fraktur linear os temporal sinistrahead up 30oringer laktat 28 tpm
ketorolac 30mg/8jam/iv
ranitidine 50mg/8jam/iv
piracetam 3gr/12jam/iv
mannitol 100cc/6jam/drips bila tensi > 100
diet biasaLab 20/3/2015
RBC: 3.45
HGB:10.6
HCT:31.9
PLT:182
WBC:13
GDS:140Ur/Cr:64/0,80
SGOT/SGP:67/47Na/Ka/Kl 141/4,1/108PT: 10.6APTT: 26
2K5B2
Agus satriya 703816
8-8-1982
MRS: 6-3-2015dr. Nasrullah, Sp.BSS : kesadaran menurunO: lemah GCS 13 (E4M5V4)Motorik
Menurun N
Menurun N
A: TCS GCS 10 dengan perbaikan GCS 13 cefadroxil 500mg/12jam/oralranitidine 150mg/12jam/oral
asam mefenamat 500mg/8jam/oral
neurodex 1tablet/12jam/oral
terapi lain sesuai T S Gizi klinik & mataLab (13-3-2015)
WBC: 11.5
RBC:3.58
HGB:10.8
PLT:382
Lab (10-3-2015)
Na: 145
K:4.5
Cl: 111
CT scan
Contusio cerebri region parietal kanan
Perdarahan subarachnoid region temporal kiri
Multihamatosinus DD/Multisinusitis
Soft tissue swelling region frontal sampai palpebra dextra
Pneumobulbi dextra
3K5B3
Abd.Halim
690039
01-05-1948
MRS:
14/3/2015
Dr. dr. Djoko Widodo Sp.BSPost cranioplasty hari IInfus ringer laktat 28 tpmCeftriaxone 1gr/12jam/ivRanitidine amp/8jam/iv
Ketorolac 1 ampul/8jam/iv
Takar drain/hari
Awasi KU dan tanda vitalLab 19/3/2015
GDS 110
WBC 5,7
RBC 4,94
HGB 13,9
HCT 44
PLT 146
SGOT 19
SGPT 10
Na/Ka/Kl 145/3,6/103
Ur/Cr 14/0,81
Lab 5/3/2015
PT/APTT 10,3/28,5
GDS 112
Ur/Cr 8/0,84
SGOT/SGPT 25/19
Albumin 4,4
WBC 7,26
RBC 5,46
HGB 15,5
PLT264
CT scan kepala 10-3-2015
Skull defect pada regio parietalis kiri
Ventriculomegaly
Encephalomalacia
Foto thorax 6-3-2015
Dilatatio elongatio et atherosclerosis aortae
4K5B4
Naruh
699446
23-09-1964
MRS :
21/2/2015
Dr willy adhimarta Sp BSS: luka region sacrumO: KU: Sakit sedang/Gizi cukup/SadarGCS 15 (E4M6V5)Motoric
5 5
2 2
Regio sacrum : luka semakin keringA: spinal cord injury
Ulkus decubitus region sacrum rencana laminoplasty
cefadroxil 500mg/12jam/oral metronidazole 500mg/8jam/oral
omeprazole 1 tablet/12jam/oral
asam mefenamat 500mg/8jam/oral
rawat luka dengan oxoferin
Lab 18/3/2015RBC : 4,54WBC : 9,6HGB : 12,5HCT : 41PLT : 419
GDS 62
SGOT 27
SGPT 20
Na/k/cl : 131/4.1/103
Lab tgl 9/3/2015SGOT/SGPT : 29/46
5.K5B5
Amiruddin
703996
28-7-1996
MRS :
17/3/2015De. Andi Ihwan, Sp.BSS: sakit kepala berkurangO: KU: Baik GCS 15
Pupil isokor
A: TCR GCS 15 maxillofacial Injury fraktur os mandibular sinistra cefadroxil 500mg/12jam/oral
Neurodex 1tablet/12jam/oral Ranitidin 50mg/8jam/IV
Cefadroxil 500mg/12jam/oral
Asam mefenamat 500mg/8jam/oral
Senmax 3x10 tetes via hidung kiri& kanan
Terapi sesua TS gizi klinik bedah plastikLab 19/3/2015
WBC 7,4
RBC 3,27
HGB 9,5
HCT 29
PLT 488
SGOT 42
SGPT 78
Lab 13/3/2015
RBC:3,08
HGB:9,7
HCT:28,4
WBC:6,6
6K5B6
Chairul Syam Hapil
702909
26-3-1990
MRS:
21/3/2015Dr. dr. Nasrullah, Sp.BSS: nyeri luka operasi berkurang
O: keadaan umum baik
GCS 15 (E4M6V5)
Regio kepala: tampak kasa penutup luka keringA:post cranioplasty hari IV ec skull defectRinger laktatCeftriaxone 1gr/12jam/iv
Ranitidine 1amp/8jam/iv
Ketorolac1amp/8jam/iv
Takar drain tiap hari
Lab 21/3/2015
WBC 7,4
RBC 4,51
HGB 14,7
HCT 42
PCT 0,3
GDS 95
Ur/Cr 18/0,80
SGOT 92
SGPT 143
Na/Ka/Kl 143/4,5/105
Lab 1/3/2015
Na/Ka/Kl 146/3,6/114
26-2-2015
B rain swelling
Hematoma subgaleal regio parietal sinistra
NOIDENTITASDPJPDIAGNOSISTINDAKANLABORATORIUM
LONTARA 3 BAWAH DEPAN KAMAR 3
1ISMAEL
16-11-2014
RM: 703889
MRS:dr. Andi Ihwan, Sp.BSS: Lemah, sesak
O: Sakit sedang/Menangis
A: Hidrocephalus + AnemiaRencana VP-Shunt
Terapi sesuai TS pediatric, subdivisi neurologis, respirologi, nutrisi metabolik
Optimalisasi KU
Bilas lambung???Laboratorium
25/03/2015RBC : 2.29
HGB : 6
HCT : 18.1
PLT : 345
WBC : 9.64
Ferritine : 299.18
Laboratorium
24-03-2015
Kultur dan sensitivitas urine
Sensitif:CeftazidimeChloramphenicolGentamicinNorfloxacinMeropenemLevofloxacinLaboratorium
23-03-20115
Mikrobiologi fesesKultur & sensitivitas Escherchia coli O157Kesan: Bakteri high pathogenicLaboratorium
19-03-2015
Mikrobiologi UrineKultur bahan lain/OAT : Tidak ada pertumbuhan bakteri aerob
2RESKI
11-07-1992
RM: 649241
MRS: 22-02-2015DR. dr. Nasrullah, Sp.BSS: Pusing berkurang
O: Sakit sedang, Pus (+)
A: Leakage CSF post cranioplasty + elevated liver enzymTunggu jadwal operasi
Metronidazole 500 mg/8 jam/oral
Ciprofloxacin 500 mg/12 jam/oral
Hp-Pro 3 dd 1 (H-10)
Kultur pus dari luka (tunggu hasil)Laboratorium
22/03/2015RBC : 5.58
HGB : 11.3
HCT : 35.8
PLT : 276
WBC : 9.7
PT : 10.8
APTT : 30.2
GDS : 113
Ureum/Cr : 14/0.6
SGOT /SGPT : 232/197
Na/K/Cl : 143/4.3/106
CT/BT : 7.00/2.00
Laboratorium :
14/3/2015SGOT /SGPT : 210/142
Laboratorium :
10/3/2015SGOT /SGPT : 209/125
Laboratorium :
07/3/2015SGOT /SGPT : 189/129
Laboratorium
04-03-2015Bilirubin total : 0.96
Bilirubin direk : 0.55
SGOT/SGPT : 225/156
Alkali fosfatase : 79
Gamma-GT : 83
Laboratorium
02-03-2015HBsAg : Reactive
Anti HCv : Non-reactive
USG abdomen
02-03-2015Tanda-tanda PID
Organ intraabdomen lainnya dalam batas normal
CT-scan kepala tanpa kontras:
17-02-2015Bone graft terpasang pada os temporoparietal sinistra disertai epidural hematoma, subgaleal hematoma, dan pneumocephal pada regio tersebut
Encephalomalacia regio frontotemporoparietal sinistra
3REZKIYANTI
18-08-1997
RM: 630827
MRS: 20-03-2015
Prof. DR. dr. Andi Asadul Islam, Sp.BSS: Tidak ada keluhan
O: Kesadaran baik GCS 15
A: Skull defectTunggu jadwal operasi Lapor OK
Konsul anastesi
Siap darah 2 bag PRC (1 ambil dan 1 siap)
Informed consent
Marking siteLaboratorium
16-03-2015
RBC : 8.2
HGB : 4.53
HCT : 39.5
PLT : 309
WBC : 8.2
PT : 10.9
APTT : 1.05
GDS : 130
Ureum/Cr : 10/0.59
SGOT /SGPT : 13/11
Na/K/Cl : 145/4.2/97
CT/BT : 8.00/3.00
Albumin: 4.4
CT-Scan kepala
17-03-2015
Kesan: Skull defect disertai encephalo malacia regio fronta dextra
Thoraks PA
Tidak tampak kelainan pada foto thoraks ini
4SYUAEBA PATAROI
24-04-1963
RM: 706144
MRS: 26-03-2015DR. dr. Nasrullah, Sp.BSS: Pusing
O: Sakit sedang, GCS 15, pupil isokor 4cm/4 cm. RC +/+
A: Trauma capitis ringan GCS 15IVFD RL 28 tpm
Ketorolac 30 mg/8 jam/IV
Ranitidin 50 mg/8 jam/IVNeurosanbe drip
Diet biasa
Laboratorium
WBC: 6.6RBC: 3.81HGB: 12.3HCT: 36PLT: 268CT/BT: 8.00/3.00GDS: 108Ur/Cr : 23/-SGOT/SGPT: 20/15Na/K/Cl: 141/3.3/108HBsAg: Non reactive
Anti HCV : Non-reacive
LONTARA 3 BAWAH DEPAN KAMAR 4
1
2HJ. HASIA
31-12-1959
RM: 705555
MRS: 20-03-2015Prof. Dr.dr>Andi Asadul Islam,Sp.BSS: Nyeri kepala
O: KU: Cukup /GCS 14 (E3M6V5), pupil isokor 4cm/4cm
RC +/+
A: Trauma capitis sedang
SAHIVFD RL 28 tpm
Ceftriaxone 1 gr/12 jam/I
Ketorolac 30 mg/8j jam/IV
Ranitidin 150 mg/8 jam/IV
Piracetam 3 gr/12 jam/oral
KJS Gizi klinik
Drips manitol 100 cc/8 jam/IV
Bila sistol 110 mmHg
Head up 30Laboratorium
22/03/2015
WBC: 12.7RBC: 3.88HGB: 11.5HCT: 35PLT: 384PT/APTT: 9.6/25.7
Laboratorium
20/03/2015WBC: 12.7RBC: 3.79HGB: 11.6HCT: 33.9PLT: 76GDS: 148Ur/Cr : 26/0.7SGOT/SGPT: 23/14Na/K/Cl: 143/4.2/110HBsAg: Non reactive
Anti HCV : Non-reaciveFoto thoraks
24-03-2015
Cardiomegaly dengan dilatatio, elongatio et atherosclerosis aortae
CT-Scan kepala
20-03-2015
Pendarahan subarachnoid Tanda-tanda brain swelling
3
4MASNY MADILIS
15-06-1987
RM: 703701
MRS: 16/03/2015dr. Nasrullah, Sp.BSS: Benjolan di kepala
O: Sakit sedang
Gizi baik
Composmentis
A: Kista epidermoidTunggu jadwal operasi
Cek lab ulangLaboratorium
25/03/2015
WBC: 6.0RBC: 5.08HGB: 13.5HCT: 39.3PLT: 301CT/BT: 7.30/3.00
PT/APTT: 10.3/24.8GDS: 104Ur/Cr : 19/0.60SGOT/SGPT: 17/12Na/K/Cl: 145/3.7/107HBsAg: Non reactive
Anti HCV : Non-reacivePA 06-03-2015
Kista epidermoid
Foto thoraks
Kesan:
Cor dan pulmo normal
Tidak ada tanda-tanda metastasis pada fot thoraks ini
CT-Scan 10 Oktober 2014
Kesan: Gambaran epidermoid cyst of the scalp
5
6NUR RIANA06-09-2009
RM: 705679
MRS: 23-03-2015dr. Willy Ahimarta,Sp.BSS: Nyeri kepala
O: Sakit sedang GCS 15
A: Post craniotomy POH-3
Fracture depress os frontalAff drain
Aff kateterAff infus
Cefadroxil syr 2x II cth
Paracetamol 3x II cthLaboratorium
23-03-2015
WBC: 15.36RBC: 4.15HGB: 11.5HCT: 32.9PLT: 286CT/BT:6.30/3GDS: 39Ur/Cr : 31/0.40SGOT/SGPT: 39/18Na/K/Cl: 137/4.2/110HBsAg: Non reactive
Anti HCV : Non-reaciveCT-Scan kepala
23-03-2015
Hematom intracerebri regio frontal dextra Depressed fractur sinistra disertai hematosinus ethmoidalis sinistra
LONTARA 3 BAWAH DEPAN KAMAR 6
1AGUSLAN
17-08-1998
RM: 705827
MRS: 23-03-2015dr. Willy Adhimarta, Sp.BSS: Nyeri kepala
O: KU: sakit sedang GCS 15
A: Trauma Capitis Ringan
Subgaleal hemoraghicIVFD RL 28 tpm
Ceftriaxone 1 gr/12 jam/IV
Ketorolac 30 mg/8 jam/IV
Ranitidin 150 mg/8 jam/IV
Diet biasaLaboratorium
23-03-2015
RBC : 3.75
WBC : 17.8
HGB : 11.5
HCT : 33.7
PLT:302CT/BT : 7.00/3.00
PT/APTT : 11.6/27.6
GDS : 139
Ur/Cr : 23/0.90
SGOT/SGPT : 34/22
Na/K/Cl : 140/3.7/107
HBsAg : Non-reactive
Anti HCV : Non-reactive
CT-Scan Kepala
24-03-2015
Brain window: Subgaleal hematom
Bone window: tidak ada
2MOHAMMAD ALIF
14/03/2014
RM: 705992
MRS: 24/03/2015Dr.dr.Nasrullah Mustam, Sp.BSS: Kepala pusing berkurang
O: Sakit sedang
Menangis kuat
Kepala membesar (+)
A: HydrocephalusTunggu jadwal operasi
Cek lab lengkap
Foto thoraks
CT-Scan kepalaLaboratorium
23/03/2015
WBC: 16.27
RBC: 5.35
HGB:
HCT:36.2
PLT: 513
PT/APTT: 13.1/26.8
Laboratorium
19/03/2015
WBC: 15.64
RBC: 4.80
HGB: 11.6
HCT:32.5
PLT: 468
PT/APTT: 13.1/26.8
Na/K/Cl : 140/49/110
CT/BT : 700/3.00
HBsAg : Non-reactive
Anti HCV: Non-reactive
SGOT/SGPT : 37/16
GDS : 93
Ur/Cr: 11/0.4
CT-Scan kepala
03/02/2015
Hydrocephalus obstruktiff ec massa pada cerebellum
Foto thoraks
30-03-2015
Kesan: Tidak tampak kelainan pada foto thoraks ini
3MOHAMMAD RISKY MONY
30-06-2004
RM: 704143
MRS: 24/03/2015Dr.dr.Nasrullah, Sp. BSS: Kepala membesar dan nyeri
O: Sakit sedang/ kesadaran baik
A: Hydrocephalus
Massa regio ventrikel IIIP : VP- ShuntRencana VP-Shunt (tunggu jadwal)
Aff infuse .
Paracetamil 250 mg/ 8jam/ oralLaboratorium
12/03/2015
WBC: 5.87
RBC: 6.39
HGB: 34.9
HCT:48.5
PLT: 469
PT/APTT: 11.6/29.5
Na/K/Cl : 145/9.0/107
CT/BT : 730/3.00
HBsAg : Non-reactive
Anti HCV: Non-reactive
SGOT/SGPT : 27/16
GDS : 92
Ur/Cr: 14/0.3
CT-Scan kepala
11/03/2015
Kesan: Massa ventrikel III disertai hydrocephalus sesuai gambaran ependymoma
Thoraks
12/03/2015
Kesan: Tidak tampak kelainan radiologik pada foto thoraks
4DIMAS RACHMAWAN SUSANTO
28-07-2000
RM: 223130
MRS: 24-03-2015Dr.dr.Djoko Widodo, Sp.BSS: Nyeri kepala
Di perut ada keluar cairan dari bekas luka operasi
O: KU: Sakit sedang GCS 15
A: Hydrocephalus post V-ShuntRencana operasi minggu 29-3-2015
Puasa
Lapor OK
Konsul anastesi
Siap darah 1 bag PRC
Informed consent
Marking siteLaboratorium
24-03-2015
WBC: 2.45
RBC: 5.91
HGB: 15.1
HCT:45.1
PLT: 297
PT/APTT: 10.4/26.2
Na/K/Cl : 141/3.9/108
CT/BT : 700/3.00
SGOT/SGPT :17/40
GDS : 70
Ur/Cr: 17/4.0
Foto Thoraks
24/03/2015
Terpasang catheter VP-Shunt bilateral yang berjalan dari cranial dengan ujung caudal kiri berada pada subdiafragma kanan dan ujung kanan tidak tervisualisasi kesan dalam rongga abdomen Cor dan pulmo dalam batas normalCT-Scan kepala
24/03/2015
VP-Shunt terpasang dengan ujung tip pada cornu posterior ventrikel lateral kiri
Hydrocephalus
Dandy walker syndrom
HCU
1Bed 1
M. Yusuf
RM: 674967
18-04-1964
Dr. dr.Djoko Widodo, Sp.BSS: Keluhan: BAB berlendir 4x
O: KU: lemah
GCS 7x (E3M4VX)Perban luka : basah
A :
Post removal tumor ec Astrocytoma High Grade IVFD NaCl 0.9% 28tpm
Omperazole 40mg/12 jam/ iv Phenytoin 100mg dalam NaCl piggybag/24jam/iv Sistenol 3x500/NGT Nebulizer ( sesuai TS pulmo Konsul GEH Terapi lain sesuai TS Gizi Klinik dan Pulmo
Lab 23-03-2015
WBC: 17,4RBC: 3,01HGB: 10,5PLT: 350Na: 133K: 3,1Cl: 104GOT: 139GPT: 142Ur/Cr: 17/0,40Albumin : 2,5
GDS : 111Lab (17-3-2015)
WBC : 18.4RBC: 3.65HGB: 12.5PLT: 415Protein total: 5.3
Albumin: 2.9
Globulin: 2.4
Kolesterol total: 231
HDL: 23
LDL: 163
Natrium: 138
2Bed 2Abdullah Rafi 18 / 7 /2006705313
Dr. dr.Djoko Widodo, Sp.BSS: Keluhan : Kesadaran menurun
O: KU : lemah
GCS 12 (E4M5V3)A: - Trauma capitis sedang GCS 9 dengan perbaikan GCS 12 (E4M5V3)- ICH temporal sinistra (PH-6) IVFD RL 12tpm
Ceftriaxone 500mg/12 jam/iv
Ranitidin amp/ 8jam/iv
Ketorolac amp/ 8jam/iv
Mannitol 50cc/ 8 jam/ jika TD > 100
Semax 3x 100 gtt (tetes hidung kiri kanan)
Observasi GCSCT scan kepala 19/3/2015
Pendarahan intracerebri regio temporal kiri
USG Abdomen 19/3/2015
Tidak tampak tanda-tanda laserasi maupun cairan bebas pada USG Abdomen saat ini
Lab 19/3/2015
Wbc: 20.5Rbc : 4.98Hgb : 11.9Plt : 335SGOT/SGPT: 120/66
Na: 149K: 4.5Cl: 114Ur / cr: 20/0.40
3Bed 3
Muh.Rusli
11-11-1981
697429
MRS :
17-01-2015Dr. dr.Djoko Widodo, Sp.BSS : Keluhan : demam
O : KU : SedangGCS : 9x (E4M5Vx)
A :
- Post Craniotomi ec EDH
IVFD Nacl 0,9% 28tpm Sistenol 3x500/KP Omeprazole 40mg/ 24jam/iv Ondansentron amp/ 24 jam/iv Cotrimoxazole 2x2/NGT
Tutup kanul seluruh Cek darah rutin, SGOT, SGPT Terapi lain sesuai TS Gizi Klinik, Pulmo
Lab (20-3-2015)
WBC : 11.3RBC: 4.67HGB: 11.5PLT: 455Ur/Cr: 16/0.54GOT/GPT: 64/212
Albumin: 3.4Na/K/Cl: 130/4.3/94
GDS: 117Foto thorax 18-01-2015
Bronchopnemunia bilateral
CT Scan kepala 17-01-2015
Perdarahan epidural region frontalis dengan fraktur kominutif os frontalis sisi kanan disertai herniasi subfalcine
Hematoma subgaleal dengan emfisema subkutis pada region frontalis sisi kanan
4Bed 4
Rangsong
17/9/1952
695412
MRS :
04-01-2015
DR.dr Nasrullah M. Sp.BSS: sulit dinilai
O:KU:lemah
GCS 8x(E3M4Vx)
A: Post craniotomy e.c ICH parietal
IVFD Nacl 0.9% 18 tpm
Ambroxol 3x1cthNGT Ventolin 2,5mg/8jam nebulizer
Sistenol 3 x 500/ KP/ NGT Tutup kanul 1/2 GV rawat luka dekubitus Rawat trakeostomi Terapi lain sesuai ts gizi klinik,pulmo, rheumatoligi
Foto thoraks (9/3/2015)
Tracheostomy tube terpasang 3.8 cm diatas carina
Dilatatio aortae
Elevasi diafragma kanan
Lab 20-03-2015
WBC: 9.2RBC: 3.45HB: 9.6PLT: 509SGOT: 43
SGPT: 27Albumin: 2.8
As. Urat: 5.6Na/K/Cl : 144/3.6/107Lab 04-03-2015
WBC: 10.0
RBC: 3.31
HB: 9.1
PLT: 313
Ur: 45
Cr:0.64
SGOT: 43
SGPT: 27
CT-Scan (28/1/2015)
-Defect os. Parietal kiri disertai herniasi parenkim
-Enchepalomalacia region temporal sinistra
-sudah tidak tampak perdarahan intraserebri, intraventrikel dan pons
5Bed 5Siti Maryam27/7/1963705430
Dr. dr.Djoko Widodo, Sp.BSS : Keluhan : Kesadaran menurun, demam
O : KU : LemahGCS : 12 (E3M5V4)
A :
- Post ventricular drainage ec IVH ec hemoragik stroke H-6
IVFD RL 20tpm Ceftriaxone 1gr/12j/iv Omeprazole 40mg/ 24jam/iv Paracetamol 1g/ 8 jam/iv Konsul neurologi Konsul kul-kel Konsul Gizi Observasi GCS Cek laboratorium lengkap
Lab 23/3/2015
Wbc: 18.5Rbc : 4.09Hgb : 12.0Plt : 335SGOT/SGPT: 120/66
Na: 145K: 4.1Cl: 110Ur / cr: 20/0.40
6Bed 6
Arsank
704873
20-04-1980MRS:15-3-2015
Dr. dr. Nasrullah, Sp.BSS: Keluhan: Kesadaran menurun
O: KU: SedangGCS 12 (E3V4M5)
A:
Trauma Kapitis Sedang GCS 12
(PH-10)
IVFD NaCl 0.9% 18 tpm O2 10 liter/menit Ceftriaxone 1gr/12j/iv Ranitidin amp/8jam/iv Manitol 100 cc/6jam jika TD > 100 Semax 4x10 gtt
Terapi lain sesuai TS Gizi Klinik
Lab (19-3-2015)
Kolesterol total: 210
LDL: 125
HDL: 49Lab (15-3-2015)
WBC : 12.9RBC: 4.71HGB: 14.3PLT: 263Ur/Cr: 21/0.90GOT/GPT: 50/26GDS: 139Na/K/Cl: 141/3.9/107
CT Scan (24-03-2015)
Subdural hygroma regio frontoparietalis bilateral
Tanda-tanda brain swelling
7Bed 8
M. Juhri
445570
31/12/1956
MRS
1/3/2015Dr. dr. Nasrullah, Sp.BsS: Keluhan: BAB lendir 4xO: KU: sedangGCS 15 (E4M6V5)A : Post op craniotomy ec SDH
IVFD RL 28tpm Bisolvon syrup 3x1cth
Na. Diclofenac 2x1/NGT
Omeprazole 40mg/24jam/iv Konsul GEH
GV rawat luka Terapi lain sesuai TS Gizi Klinik, pulmo, rheuma
Urinalisa (21-3-2015)
pH : 7.5
Nitrit : positif
Blood : +/10
Lekosit : +++/500
Sedimen lekosit : 25
Sedimen eritrosit : 2
Sedimen epitel sel : 2
Lab (20-3-2015)
WBC : 11.0RBC: 2.95HGB: 7.5PLT: 877Na/K/Cl: 141/4.5/105
As. Urat: 4.1
Albumin: 2.5
8Bed 7
Abdul Rauf
677206
01/07/1969
MRS :
25-08-2014Prof. Dr. dr. A. Asadul Islam Sp.BSS: Keluhan : Kejang, keluar darah dari NGT
O : KU : lemah
GCS 7x (E3M4Vx)
NGT : + 500 cc warna kehitaman
A :
- Post repair VP shunt H-8
- Post craniotomy ec SDH
IVFD RL 20 tpm
Ceftriaxone1gr/12jam/iv
Omeprazole 40mg/24jam/iv Phenytoin 100 mg dalam NaCl piggy bag/8 jam/drips
Jika kejang ( diazepam 1 amp dalam NaCl piggy bag/16 tpm
Sistenol 3x500/kp/ngt Awasi KU dan tanda vital Cek darah rutin
Lab (25-3-2015)
WBC : 20,4RBC: 4,20HGB: 12,5PLT: 516GOT/GPT: 88/99Ur/Cr: 28/0.30
Asam urat : 2.8
Protein total : 7.3
Albumin : 3.1
Globulin : 4.2
Kolestrol total : 132
Na/K/Cl : 136/4.7/106Lab (10-3-2015)
WBC : 9.9RBC: 3.68HGB: 11.0PLT: 537
GOT/GPT: 27/41
Ur/Cr: 21/0.38
MSCT Kepala Non Kontras (09-03-2015)
Defect pada os temporalis kiri dengan herniasi parenkim otak region tersebut
Encephalomalacia region frontalis bilateral dan temporoparietalis kiri
Hypertensive Hydrocephalus
Foto thoraks (09/03/2015)
VP shunt terpasang pada hemithorax kanan dengan tip kesan pada rongga abdomen
Tracheostomy tube terpasang pada trachea setinggi 4 cm diatas carina
TB paru lama tenang
Elevasi diafragma kiri
Dilatatio et elongation aortae
Rahmi
706365
8-8-1999Dr andi ikhwan,Sp.BSS: kesadaran menurun
O: sakit berat. Gizi baik
Status lokalis
Tampak hematom pada palpebra kanan.
Nyeri tekan ada
A: trauma capitis sedang GCS 10 O2 10 liter/menit Nacl 0,9% 28tpm Ceftriaxone 1gram/12jam/iv Ketorolac 30mg/8jam/iv Ranitidine 50mg/12jam/iv Mannitol 200cc, maintenance 100 cc/6jam jika TD>100Lab (27-3-2015)
WBC : 18,6RBC: 4.04
HGB: 10.4PLT: 290Ur/Cr: 20/0.40GOT/GPT: 48/22GDS: 128
Na/K/Cl: 139/3.5/108CT scan 27-3-2015
Pendarahan Subarachnoid
- Pendarahan intracerebri lobus temporalis kiri
- Pendarahan epidural regio temporal kiri
- Fraktur os frontalis dextra disertai hematosinus ethmoidalis kanan
- Brain swelling
Foto cervical AP Lateral 27-3-2015
Spondylolisthesis CV C2 terhadap C3,C3 terhadap C4,C4 terhadap C5
PALEM BAWAH
2B2K8 BED2
Hamjaya
676472
04-01-73
MRS
17-03-2015DPJP
Dr.Andi Ichwan,
Sp.BS
S. keluhan: kedua kaki tidak dapat digerakkan
O. KU : sedang
Motorik
5
5
0
0
A.paraplegi ec. Destruksi vertebra thoracal VIIIP/
IVFD. RL :D5= 2:1
Ceftriaxone 1g/12j/iv
Ranitidin amp/12 jam/iv
Methylcobalamin/ 8j/iv
Methylprednisolon amp/8j/iv
Rencana laminektomi -> tunggu jadwalLab
(17/03/15)
BT: 7.00
CT: 3.00
PT/APTT: 11.2/ 27.3
INR: 1.10
GDS: 76
UR/CR: 65/3,5
GOT/GPT: 35/20
NA/K/CL: 142/3.7/106
PALEM ATAS
1.
2B1K5
Nabil anansyah
679109
03-01-2011
MRS
23-03-2015DPJP:
Dr. Nasrullah, Sp. BSS. keluhan nyeri
O. GCS15( E4M6V5)
Pupil isokor 3mm/3mm
RC+/+
A.smpost cranioplasti hari- 1p/ instruksi post operasi
- IVFD RL 10tpm
- ceftriaxone 250mg/12/iv
- renitidin 1/2 amp/12j/ iv
- paracetamol 200mg (20cc)/8j/iv
-takar drainase
- jika sadar baik boleh minumLab
(17/03/15)
GDS: 77
UR/CR: 13/0.59
GOT/GPT: 27/12
ALB: 3.5
NA/K/CL: 149/4.6/112
RBC: 4.99
HB: 13.3
HCT: 39.7
PLT: 357
WBC: 10.03
BT: 7.00
CT: 3.00
PT/APTT: 11.1/ 35.2
INR: 1.07
titipanLONTARA 3 BAWAH BELAKANG
1HCU Bed 4
ST. Nurnaini
703931
28/12/1952
MRS :07/03/2015
DPJP
Dr. dr. Djoko Widodo, Sp.BS
S:kesadaran menurun
O: KU:
GCS 5 (E1M5V2)
A: post op H2 ec meningioma
Infus RL 28tpm
Ceftriaxone 1gr/12j/IV
Ketorolac 30mg/8j/IV
Ranitidin 50mg/8j/IV
Headup 300Ganti Verban /2hari
Lab 15/03/2015
RBC : 3,73
WBC : 28,300
HGB : 11,3
HCT : 33
PLT : 308,000
Ur/Cr : 22/0,30
Na/K/Cl : 137/2,8/102
Lab 13/03/2015
RBC : 3,44
WBC : 20, 300
HGB : 10,4
HCT : 31
PLT : 182,000
PT/APTT : 10,8/31
Ur/Cr : 37/0,40
SGOT/SGPT : 22/26
GDS : 100
Alb : 2,5
Na/K/Cl : 140/ 2,7/107
CT-Scan Kepala (tanpa kontras) 07/03/2015
-Massa extraaxil regio frontotemporalis suspek meningioma disertai brain swelling dan tanda-tanda herniasi subfalcine dan trans tentorial
- Hydrocephalus obstruktif
- Encephalomalacia pons sisi kanan
2K3B5
Sampara Dg Sibali
RM : 705407
Tgl lahir
01/07/1963
Tgl MRS
19/03/2015S:
O: Ku = Baik
A : Multiple Abses Cerebri dan CerebellumTerapi sesuai TS Saraf
Tunggu Konfirmasi bagian sarafLab 19/03/2015
WBC: 24.6
RBC: 4.07
HGB: 11.9
HCT: 35.7
PLT: 341000
CT/BT: PT/APTT: GDS: 95
Ur/Cr: 29/0.9
SGOT/SGPT: 24/1.1
Na/K/Cl: 140/3.6/102
HBsAg: nonreactive
MSCT Kepala
20/03/2015
Multiple Abses Cerebri dan Cerebelum
3K4B4
Karmila
RM: 699522
Tanngal lahir:
20-10-1966
Tanggal konsul:09-03-2015DPJP:
Dr.dr.Djoko widodo,Sp.BSS: nyeri kepala, penglihatan kabur
O: status generalisata sakit sedang/ gizi cukup
GCS15
Pupil isokor
A: POH 2 LobectomyPOH 2 LobectomyLab 09-3-2015
HB: 15.9HCT: 45.4WBC : 9.9RBC : 5.04PLT : 234GDS: 102Ur/cr : 23/0.60GOT/GPT : 26/57Elektrolit: Na/K/Cl: 141/4.3/105
LONTARA 3 THT ATAS DEPAN
1K1B3
Sartiani
MR: 705635
Tanggal lahir:
1-5-1963DPJP:
Dr. Willy Adhimarta, Sp. BSS: Nyeri kepala
O: GCS 15
Region occipital sinistra: tampak luka terjahit untuk 5x2 cm, hematoma tidak ada
A: Trauma kapitis ringan GCS 15- RL 10 tpm
- Ceftriaxone 1gr/12j/iv
- Ketorolac 30mg/8j/iv
- Ranitidine 50mg/8j/ivLab (22-3-2015)WBC: 18,8RBC: 4,86HGB: 14,9HCT: 43PLT: 223GDS: 185Ur/Cr: 23/ 0,6
2Simon Seda
705167
01-01-1945
MRS:
17-03-2015
DPJP:S: keluhan : Kesadaran Menurun
O: Sakit Sedang
GCS 11(E3M5V3)
A:
Post craniektomi hari ke-1 SDH tempoparietal sinistra ICH temporal sinistraInstruksi post OP
IVFD RL 28 tpm
Ceftriaxone 1gr/12j/iv
Ranitidin ampl/8j/iv
Ketorolac amp/8j/iv
Feniton 100mg dalam Nacl piggy bag/8j
Cek HB post op
Asam traneksamat amp/8jLab 17-03-2015
RBC : 4.88
HGB: 12.6
HCT: 37.7
PLT:242
PT : 10.5
APPT: 28.5
GDS:190
UR/CR: 25/1.10
SGOT: 31
SGPT: 19
NA/KA/KL:140/4.3/103
3Rukka Lindung
659418
24-4-1959
MRS:
24-3-2015DPJPS: Nyeri kepala
O: Status generalis
KU: Lemah
A: Tumor intrakranialInfus RL: dextrose 5% 2:1
Mannitol 100cc/6 jamLab 16/03/2015
WBC 8750RBC 3.35HGB 10,6HCT 31.1PLT 364GDS 90Ur/Cr 28/0,80SGOT/SGPT 21/18Na/K/Cl 134/4.6/99
4Simon Seda
705167
01/01/1945
MRS
17/03-2015S:
O: status generalisata sakit sedang/ gizi cukup
GCS15
Pupil isokor
A: POH craniectomyCeftriaxone 1gr/12jam/iv
Ranitidin 50mg/8jam/iv
Neurobion 5000iu/24jam/ivLab 1403/2015
WBC 20.61RBC 5.27HGB 10.3HCT 33.9PLT 228000GDS 164Ur/Cr 26/1.0SGOT/SGPT 26/13Na/K/Cl 138/4.6/105
LONTARA 3 ATAS BELAKANG
1K2B6
N. Zulkarnaen
687335
31/12/1962
MRS
!9/03/2015DPJP
dr. Nasrullah Sp.BSS: Tidak ada batok kepala
O: : status generalisata : SS/GC/CMGCS 15 pupil isokor2mm/2mm,RC +/+A: Skull Defect Regio Frontal Dextra
Rencana Cranioplasty hari Selasa 24/03/2015Lab 1403/2015
WBC 7300RBC 5.27HGB 15.3HCT 46PLT 297000CT/BT 800/230GDS 108Ur/Cr 30/0.90SGOT/SGPT 24/28Na/K/Cl 146/4.4/109
2K3B4
Rizaldi Winata
705995
27/12/1997
MRS:
24/03/2015DPJP
Dr. dr. Nasrullah, Sp.BSS: Nyeri kepala
O: Status generalis:
SS/GC/CM
GCS 15
A: TCR GCS 15- RL 10 tpm
- Ketorolac 30mg/8j/iv
- Ranitidine 50mg/8j/iv
- MannitolLab 2403/2015
WBC 10,1RBC 3,88HGB 11,7HCT 35,0PLT 678GDS 85Ur/Cr 14/0,60SGOT/SGPT 53/80
3K4B4
Anggun Febriyani
705459
27/2/2000
MRS:
20/03/2015DPJP: Prof Dr. dr. Andi Asadul I, Sp.BSS: Nyeri kepala
O: Status generalis:
SS/GC/CM
GCS 15
A: TCR GCS 15- RL 10 tpm
- Ketorolac 30mg/8j/iv
- Ranitidine 50mg/8j/iv
Lab 20/03/2015
WBC 9,9RBC 5,07HGB 14,7HCT 43,2PLT 403GDS 131
Na/K/Cl: 141/5,2/106
4Fauzan M N
706124
09/06-2006
25-03-2015
S: Nyeri luka operasi
O :KU baik GCS 15
A: POH 2 CraniectomyRL 20 tpm
Ceftriaxone 1gr/12jam/iv
Ketorolac 30mg/8jam/iv
Burnazin ZalfLab 25/03/2015
WBC 13.5RBC 4.46HGB 13.3HCT 35.5PLT 844GDS 120Ur/Cr 24/0,38SGOT/SGPT 53/80Na/K/Cl 143/4,5/109
LONTARA 4 ATAS BELAKANG
1K7B6
Ayu Andini
22/11/2003
704797
MRS:
14/03/2015S: Lemah kedua tangan dan kakiO: : status generalisata : SS/GC/CMGCS 15 pupil isokor3mm/2mm,RC +/+A: Tetraparese ec SOLTunggu hasil kulturLab 14/03/2015
WBC 7600RBC 4,76HGB 13,2HCT 39,3PLT 500GDS 90Ur/Cr 20/0,40SGOT/SGPT 15/21Na/K/Cl 144/4,4/113
2Putra Ansar
10/05/2014
701432
MRS:DPJP:S: Demam ada, spastik ada
O: status generalisata : SS/GC/CMGCS 15 pupil isokor3mm/2mm,RC +/+A: Post VP shunt- RL 10 tpm
- Ketorolac 30mg/8j/iv
- Ranitidine 50mg/8j/iv
ICU
1.Bed 1
Herman
RM: 70-58-48
24-08-1965
DPJP:
Dr.willy adhimarta,Sp.BSS: Kesadaran menurun
O: KU: lemah
Pupil isokor
drain 100 cc
A:
Post Op cranitomoi decompress + external drainage ec ICH Terapi sesuai Ts anestesi
GV/3 hari
Takar drain/24jamLab 23-03-015
Wbc:14.3
Rbc :372
Hgb :11.3
Hct: 33.8
Plt :303
PT/APTT: 10.3/33.2
GDS: 163
SGOT/SGPT: 24/22
Na/k/cl:148/3.3/112
Ur / cr:51/1.40
HBsAg:non reactive
2.Bed 2
Mastang
699916
01/07/1996
Tanggal Konsul :
04-02-2015
DPJP :
Dr. dr. Nasrullah, Sp.BSS : keluhan sulit dievaluasi
O : KU : sedang
GCS : 6x (E4M2Vx)
A : - SOL Intracranial
Post VP shunt e.c hydrocephalus
post op external drainase ec SOH
Infus RL 20 tetes/menit
Terapi lanjut TS. Anastesi dan BTKV
Ceftriaxone 1gr/12jam/iv
Ganti verban/3 hari
Foto Thoraks PA/AP
(17/02/2015)
Kesan : - Bronchopneumonia dextra
- Tidak tampak tanda-tanda metastasis pada foto thorax ini
Lab 15/03/2015
RBC : 2.97
WBC : 7, 900
HGB : 9, 3
HCT : 27
PLT : 320, 000
Ur/Cr : 33/0, 40
Na/K/Cl : 141/ 3,0/ 106
AGD 15/03/2015
pH : 7,595
PCO2 : 34,8
PO2 : 240,4
SO2 : 99,4
BE : 12,2
HCO3 : 34,0
Laktat darah : 1,4
MSCT Kepala (AX+ Cor) Non Kontras
(12/03/2015)
Kesan : Subdural hematom subkronik
- Massa fossa posterior
3.Bed 5
Herman
RM :70-56-05
21-04-1993
MRS: 21-03-2015
Dr. Willy Adhimarta,
Sp.BSS:kesadaran menurun
O : Ku: sedang
GCS 7x (E2M5Vx)
Pupil isokor
Drain 20 cc
A :
Post op H craniotomy ec ICH temporoparietal sinitra
Terapi sesuai TS anestesi
Takar drain/24 jamLab 24-03-2015
WBC: 6.5
RBC:3.66
HGB: 10.9
PLT: 88
HCT: 32.4
GDS: 148
Albumin: 3,5
Na: 147
K: 2.6
Cl: 109
GOT: 138
GPT: 248
Ur/Cr: 33/1.20
4.Bed 7
Sugiyati
703486
20/02/1953
MRS :
03-03-2015
DPJP :
Dr. dr. Nasrullah, Sp.BSS:keluhan: kesadaran menurun
O : Ku: lemah
GCS 11 (E3M5V3)
Pupil isokor 2mm/2mm
Hemiplegia sinistra
A :
-ICH parietal dextra
Stroke hemorrhagic
Post op craniectomy + external drainage POH 2
Terapi lanjut sesuai TS anestesiLab 15/03/2015
RBC : 3,74
WBC : 8,900
HGB : 10,2
HCT : 30
PLT : 165,000
Alb : 2,1
Na/K/Cl : 149/2,8/111
Lab 12/03/2015
RBC : 4,52
WBC : 4,000
HGB : 11,5
HCT : 36
PLT : 74,000
PT/APTT : 10,9/32,2
Ur/Cr : 66/0,56
GDS : 486
SGOT/SGPT : 47/69
Alb : 2,1
Na/K/Cl : 147/2,8/114
Laktat darah : 36,9
Foto thoraks AP/PA
(07/03/2015)
- Terpasang Tracheostomy tube dengan tip berada setinggi 2,27 cm dari carina
- Terpasang CVC pada hemithorax dextra dengan tip berada pada paravertebra kanan setinggi CV Th V
- Cardiomegaly dengan Edema Paru
- Dilatatio aortae
RSUH
ICU bed 4
Franky Sia
036661
06/12/1958
MRS
13/03/2015
DPJP: dr.Willy Adhimarta, Sp.BSS: Nyeritulangbelakang
O: status generalisata : KU membaik
GV, keluarkan pusA: post-laminektomi + GCS 7X, perbaikan GCS 15 Infus RL 28 tpm
Meropenem 1gr/ 12 jam/ IV
Levofloxacin 750 mg/ 12 jam/ IV
Piracetam 3gr/8 jam/IV
Ranitidin 50 mg/8 jam/IV
GV/ hariLab (19/03/2015)
WBC : 4,800
RBC : 3,53
HGB : 8,6
HCT : 28,5%
PLT : 155,000
Alb : 2, 9
GDS : 114
Na : 142
K : 3,3
Cl : 103
Foto thorax AP (15/03/2015)
Kesan : edema paru
326
RisalDPJP :
Nasrullah,Sp.BSKista Epidermoid Frontal
POH 3-Boleh Rawat Jalan Besok
401
Muhtar
20/4/1950
037334DPJP: dr.Willy Adhimarta, Sp.BSGlioblastoma Multiforme
Edema cerebri-Pro radioterapi
UGD
NurhayatiDPJP :
Nasrullah,Sp.BSTumor Hipofise ResidifRencana op. Removal Tumor via endoscopy trans nasal
PCC
NICU
1Kamar II B
Muh Raif Yamin
22-02-2015
703885DR. dr. Nasrullah, Sp.BSS :keluhan sulit di evaluasi
O : KU sakit sedang
Patensi shunt baik
A : post VP shunt ec hydrocephalus (hr IV)Ceftazidime 110mg/12j/iv
Amikasin 55mg/24j/iv
Terapi lain sesuai TS paediatric
Lab 26-03-15
WBC 9,1
RBC 3,79
HGB 11,9
HCT 36
PLT 442
CT scan kepala (tanpa kontras) 9-3-15
severe Hydrocephalus non communicans
2Kamar IIABy Ny Aztria
18-03-2015
705651
DR. dr. Nasrullah, Sp.BSS : kepala membesar
O : KU sakit sedang
Lingkar kepala 43 cm
A : hydrocephalusTerapi sesuai TS paediatric
Konsul perioperativeFoto thorax 25-03-15
-terpasang gastric tube dengan tip berada pada rongga abdomen
-cor dan pulmo normal
Lab 25-03-2015
WBC 9,2
RBC 3,09
HGB 11,0
HCT 39
PLT 280
GDS 101
Bilirubin total 11,21
Bilirubin direk 0,39
Albumin 3,1
Na/K/Cl 141/4,0/119
CT scan kepala (tanpa kontras) 22-03-15
Severe Hydrocephalus
PICU
1Arkab Manggazali
22-01-2015
705877dr. Willy Adhimarta, Sp.BSS : kejang
O : KU sedang
GCS 15 (E4M6V5)
CT scan subdural hematoma pada regio parietal kiri
A :
Acquired p complex depressed syndrome
Subdural hematoma regio parietal kiri
Rawat sama
Terapi konservatif
Terapi anticonvulsan sesuai TS peadiatricLab 27-03-15
GDS 108
Albumin 3,0
Na/K/Cl 136/4,0/107
Kalsium 8,1Lab 26-03-15
WBC 8,8
RBC 3,36
HGB 10,3
HCT 31
PLT 193CT scan kepala 24-03-15
Tidak tampak kelainan radiologik pada CT scan kepala ini
UGD
1Herlan Jasmin
17-02-1982
706279A: TCS GCS 12IVFD RL 28 tpm
Ceftriaxone 1g/12J/IV
Ketorolac 1 amp/8j/IV
Ranitidin 1 amp/8j/IV
Lab 27-03-15
WBC 15,1
RBC 5,00
HGB 15,5
HCT 44
PLT 334
GDS 173
Ur/Cr 27/0,82
SGOT/SGPT 80/32
Na/K/Cl 144/3,3/110
BT/CT 3,00/7,00
PT/APTT 10,4/23,4CT scan kepala 27-03-15
-contusio cerebri
-brain edema
-multiple fracture disertai multihematosinus
-hematom subgaleal regio frontotemporal kiri
19